The Aroostook County Medical Center intends to improve chronic care health management in northern, eastern and central Maine by planning for standard exchange of clinical information for patient transitions from acute to nonacute care. When the planning is finalized the region's primary care physicians, outpatient specialists, home health providers, nursing homes, and hospitals will have a well-defined and -supported process to improve patient care coordination and facilitate availability of patient data when and where needed. Long-term outcomes include the following: 1) An IT process template is available for chronic disease; 2) evidence-based primary care guidelines with rural relevance will be incorporated into technological templates; 3) a shared vision will drive the development of technology; 4) physician champions act as integration and adoption leaders; and 5) model of regional collaboration is developed with input from patients, payers, and providers. [unreadable] [unreadable] [unreadable]